Status of waste disposal of sharps outside medical institutions for patients with diabetes: A systematic review

Objectives As the number of people with diabetes increases, so does the amount of household-generated sharp waste, and incorrect sharp disposal methods can expose the public to needle stick injuries This systematic study assesses the relevant factors and current situation of the disposal of sharp waste in diabetes patients. Methods In this review, our study comprehensively searched PubMed, MEDLINE, Cochrane Library, EMBASE, Web of Science, and China Biomedical, Wanfang, and CNKI for the concepts of "sharps waste disposal" and "diabetes". Result In 12 identified articles, there are 4155 patients with diabetes. The findings highlight that diabetic patients have a positive attitude towards sharps waste disposal, but lack knowledge and practice of sharps waste disposal, and need to take appropriate measures to improve the rate of proper waste disposal before and during use. Patients with longer duration of diabetes are more likely to engage in inappropriate sharps disposal behaviors. Conclusions The findings emphasize that the majority of diabetic patients are unable to handle sharps safely, so more research is needed to find factors associated with sharps waste disposal in diabetic patients and to focus on sharps waste disposal behaviors in patients with longer duration of disease in future clinical practice. Trial registration PROSPERO ID. The review was registered on PROSPERO (registration number: CRD42023427592) https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023427592.


Introduction
Approximately 422 million people worldwide have diabetes mellitus (DM), and its prevalence has been increasing over the past decades [1].The World Health Organization defines sharps as "objects that can cause cuts or puncture wounds, including needles, hypodermic syringes, scalpels, etc [2].It is estimated that nearly 29% of people with diabetes require insulin to control their blood glucose levels, and maintaining optimal glycemic control usually requires patients to perform self-monitoring of blood glucose (SMBG) [3][4][5].More than 2 billion needles and syringes are used annually for self-injection in patients with diabetes [6].However, sharps handling in the home setting is less studied and less addressed, resulting in inconsistent approaches to proper sharps use, which increases the risk of needlestick injuries and infections in the home [7][8][9].
Historically, most of the public health consequences of diabetes have been described as complications and economic burdens [10], but the environmental impacts and public health risks associated with unsafe disposal of sharps arising from diabetes self-management have been rarely discussed [5,11].Proper disposal of medical sharps as part of patient education on self-injection techniques is often overlooked, leading to potentially unsafe disposal practices [12][13][14][15].Improper disposal of sharps waste not only causes environmental contamination [16], but also poses a great danger to all those who inadvertently dispose of common household waste [17].For example, not only workers at material recovery facilities, but also landfill workers and those who collect household waste are exposed to considerable risks.[18,19] Each year, approximately 5.2 million people worldwide die from diseases caused by improper sharps waste management [20].Improper disposal of sharps can lead to the spread of several diseases such as hepatitis B, hepatitis C, and AIDS, and put people who come in contact with these sharps at risk [21][22][23][24].This can become a serious public health problem because these diseases are chronic infections that often go undetected for a long time [25].
As far as we know, there are no systematic studies to evaluate diabetic patients for sharps waste disposal.The purpose of this study was to collect all available data, analyze the factors affecting it, and understand the knowledge, practices, and attitudes of diabetic patients regarding sharps waste disposal in order to provide valuable scientific information to health care decision makers.

Material and methods
After a database search, a total of 1347 possible items were identified, as shown in Fig 1 .Of these projects, 1325 were reused and subsequently excluded.After preliminary screening of the remaining article abstracts, it was determined that 929 articles did not meet the inclusion/ exclusion criteria.A total of 36 articles were identified for full text review.Only 12 of these 56 studies met the necessary inclusion/exclusion criteria.Systematic review were performed according to (PRISMA) Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines [26,27].The review was registered on PROSPERO.

Search strategy
We search of eight databases, including PubMed, MEDLINE, Cochrane Library, EMBASE, Web of Science and Chinese Biomedical, Wanfang, and CNKI, was conducted on waste disposal of sharps outside medical institutions for patients with diabetes.Databases were systematically searched using free-text terms related to 'disposal of sharps waste' and 'diabetes' were searched to February 2023.

Selection criteria
We have developed a series of inclusion and exclusion criteria to determine articles related to waste disposal of sharp tools outside medical institutions for diabetes patients.Inclusion criteria are as follows: (1) These articles should be related to the disposal of sharp waste by diabetes patients outside medical institutions.(2) This article should describe the behavior of waste disposal with sharp tools (such as whether they will be thrown into household waste or whether they have been injured by needles).

Data extraction
Extract the characteristics included in the study, including author, country, study design, sample, age, duration of diabetes, duration of insulin injection, and sharp waste disposal related situations.The extracted data were analyzed using a comprehensive method of descriptive and narrative analysis.Quality assessment was done by using the Cochrane 5.1.0system [28] evaluation manual to evaluate the bias risk to include in this systematic review See Table 1.

Influencing factors of sharp weapon treatment in diabetes patients
Impact of social and demographic factors.We explored studies on the management of sharps waste outside of healthcare facilities in diabetic patients from different perspectives.Overall, according to the literature review, sharps waste disposal did not vary by age, gender, glycosylated hemoglobin level, body mass index, race/ethnicity, or the number of insulin needles used [5,31].Place of residence, education, duration of diabetes and English literacy had a significant effect on appropriate sharp waste disposal.In particular, people with longer duration of diabetes were more likely to engage in inappropriate sharp disposal behaviors, with studies showing that the lowest rate of correct disposal (36%) was reached at diabetes diagnosis more than 30 years ago, and that type I diabetes was better able to dispose of sharp waste than type II diabetes, which may also be related to the duration of diabetes [5,33,37].Other variables.The extent to which willingness to accept physician recommendations from health care providers regarding rapid waste disposal, knowledge and practice of sharps waste disposal had a significant relationship with sharps waste disposal ability in patients with diabetes [29,33,34,36].

Status of sharps waste disposal for diabetics
Knowledge of sharps waste disposal.The results of the study indicate that knowledge of sharps waste disposal is low among people with diabetes [36][37][38], with Choo results showing that the mean level of sharps disposal knowledge among participants was 5.90 ± 1.84 [35].Most people with diabetes had not been educated about safe tool disposal practices or instructed on proper handling of insulin pens or needles, and Corte-Real indicated that approximately 19.0% of patients reported that health care professionals (i.e., medical, nursing, or pharmacy staff) provided them with information about proper medical tool disposal [10], and Hasan results showed that only about one-fourth of participants in both groups received advice on sharp disposal from their health care provider [34].
Practice of sharps waste disposal.The majority of patients reported that they had no formal training in sharps waste disposal [5,32], and 80.7% of respondents had poor behavior [30].The few respondents who had received proper sharps waste disposal would put sharps waste in plastic or glass bottles before sending it to a healthcare facility for disposal [33,38].Other incorrect methods used to dispose of sharps were measures such as throwing them into the street, toilet pits, household dumps, and public waste [10,35,37].Three studies have reported needle stick injuries to patients or their families as a result of incorrect sharps waste handling [5,33,35].
Attitude of sharps waste disposal.The majority of participants had positive attitudes toward sharps waste disposal, with Li's results showing that 70% of participants claimed to be very or somewhat confident in the correct disposal method [5]; Choo showed that the majority (46.15%) of participants had positive attitudes, but 25.30% were neutral toward sharp disposal [35]; Khan showed that 51.7% of subjects were each considered to have a high attitudes [37].People would also like to receive more verbal information about the aspects of sharps waste disposal or be able to access information by visiting their municipal websites [31,32].

Discussion
In the early stages of the diabetics, insulin injections and blood glucose monitoring are more cautious [39].Due to the chronic nature of the disease, diabetics with longer-lasting diabetes may become tired and frustrated by the prolonged use of medications and ongoing self-management, so they may gradually neglect their diabetes self-care [34,40].Over time, people with diabetes may progress to more severe disease with a variety of complications.Thus, a longer duration of diabetes may impair their diabetes-related self-management and self-care activities, including their acutely dispositional behaviors [33].
Some of the known barriers to safe disposal include a lack of information on how and where to dispose, a lack of appropriate advice from healthcare professionals, the mistaken belief that sharps disposal information applies only to illicit drug users, and the potential for patients to use community sharps disposal services that may reveal their diabetic status [13][14][15].To resolve this paradox, it is necessary to improve the correct rate of sharps waste disposal before and during the use of sharps in diabetic patients.

Diabetic patients before using the relevant sharps
The fundamental step can be to provide professional training for health care professionals.At present, nursing staff have insufficient knowledge about the safe disposal of out-of-hospital sharps waste and lack relevant knowledge reserves [41].Hospital managers should regularly train nursing staff on sharps waste management classification [10], disposal and related legal and regulatory knowledge, only when medical staff's cognitive level is improved and their importance is increased can they play a good guiding role for patients.
Simultaneously, we can provide a variety of educational methods and content.Hasan implemented a health education based on the health belief model for sharps waste disposal for community diabetic patients in the form of lectures [34], demonstration guidance and distribution of pamphlets.The level of sharps waste disposal knowledge in the intervention group was significantly improved through an educational approach to medical sharps for diabetes treatment and the proper handling of sharps prior to disposal [34,35].Future training for diabetic nurses on sharps disposal outside of medical institutions and incorporating education on safe sharps disposal into daily health education for diabetic patients; peer education, lectures, home visits by community nurses or internet sites to enhance knowledge and methods of safe sharps disposal for diabetic patients in outpatient clinics, wards and communities [10,39].

Diabetic patients in the process of using the relevant sharps
Several studies have shown that patients are injured by needlesticks when using sharps, so it is important to use safe instruments and sharps containers [5,10,33].When the sharps container is full, the nurse should instruct the patient to seal the sharps container with a warning sign such as "sharps waste" and then place the container in a hazardous waste bin or send it to a nearby medical facility for disposal.When patients do not have a dedicated sharps container, they can be instructed to use a glass container so they can safely collect and dispose of sharps waste [17,30].Government environmental departments or community health centers should give patients appropriate incentives in the early stages of promoting standardized disposal of household sharps waste [32,41], such as exchanging new and used needles, free sharps collection boxes, and free blood glucose monitoring, which can motivate more patients to collect and dispose of household sharps waste in a conscious and regulated manner.The government should establish convenient household sharps waste collection terminals: household sharps waste collection sites should be set up in public places such as communities, streets, parks, and shopping centers [31].

Limitations
There are several limitations of such systematic overviews.On the one hand is the search source, although we tried to improve our search strategy by searching multiple databases using relevant keywords and consulting academic librarians, we inevitably missed some literature, especially relevant research conference proceedings published by non-governmental organizations.On the other hand, as far as the analytical methods of literature search are concerned, this study did not conduct a comparative temporal analysis of the literature across time, and to some extent, it could not fully reveal the technological and sociocultural influences on the behavior of sharps waste disposal in diabetics.In the future, the introduction of knowledge mapping could be considered to map the topics of the documents at different stages.

Conclusion
There is less research on sharps waste disposal practices in the home setting and incorrect disposal practices increase the risk of needle stick injuries and infections in the community.Our study points out that currently diabetic patients have positive attitudes toward sharps waste disposal, but there is a lack of knowledge and practice of sharps waste disposal and longer duration diabetics are more likely to adopt inappropriate sharps disposal behaviors.Therefore, appropriate measures need to be taken before and during sharps use to improve the rate of proper sharps waste disposal by providing professional training for health care professionals, providing diverse training modalities for diabetic patients, and providing safe sharps boxes, in

( 3 )
This article should focus on diabetes patients.(4) These articles should be published in peer-reviewed journals or meeting minutes.

Table 1 . Risk of bias assessment in the included literature. Author / year Stochastic method Assignment hidden Blinding Result data integrity Results were reported selectively Other sources of bias
Note: U = unclear; Y = yes; N = no.https://doi.org/10.1371/journal.pone.0288993.t001